Comparison of respiratory infections before and after percutaneous tracheostomy.

BACKGROUND: A tracheostomy is often performed when patients cannot be weaned from mechanical ventilation. Respiratory infections (ventilator-associated pneumonia and infection of the lower respiratory tract) complicate the course of hospitalization in patients receiving mechanical ventilation. OBJECTIVES: To evaluate respiratory infections before and after a percutaneous tracheostomy and to describe their outcomes. METHODS: Medical records of adults who had percutaneous tracheostomy during a 1-year period at a tertiary care hospital in the southeastern United States were reviewed retrospectively. RESULTS: Data for 322 patients were analyzed. Patients were predominately male (63.0%) and white (57.8%), with a mean age of 57.4 years. Ventilator-associated pneumonia or infection of the lower respiratory tract was identified in 90 patients (28.0%); the majority of infections were lower respiratory infections. Of all infections, 52% occurred before the tracheostomy, and 48% occurred after the procedure. Respiratory infections were associated with longer stays and higher costs, which were significantly higher in patients in whom the infection developed after the tracheostomy. Gram-negative organisms were responsible for the majority of infections. CONCLUSIONS: Data related to respiratory infections that occurred before a tracheostomy were similar to data related to infections that occurred after a tracheostomy. Most infections were classified as lower respiratory infection rather than pneumonia. Infection, before or after a tracheostomy, resulted in longer stays and higher costs for care. Interventions focused on preventing infection before and after tracheostomy are warranted.

Characteristics, resource utilization, and nursing care of patients who undergo percutaneous tracheostomy.

PURPOSE/OBJECTIVES: Many critically ill patients require a tracheostomy when unable to be weaned from prolonged ventilator support. This study describes the characteristics, resource use, and outcomes of patients who required a tracheostomy for failure to wean from mechanical ventilation. DESIGN: A retrospective descriptive study was conducted to analyze data from the electronic medical record and hospital databases. SETTING: The setting was a tertiary care hospital with a level I trauma center. SAMPLE: Data from 363 adult subjects who underwent a tracheostomy after prolonged mechanical ventilation during a 1-year period were obtained from hospital databases. All underwent a percutaneous procedure. The majority of subjects were male (62.8%) and white (57.9%), with a median age of 59 years. Nearly half had a trauma diagnosis. RESULTS: Hospital mortality was low (9.9%). Ventilator days, hospital/intensive care unit lengths of stay, and costs were high. Only 7.1% of subjects were discharged directly from the hospital to home. Others were transferred to long-term acute-care hospitals, rehabilitation centers, skilled nursing facilities, and other hospitals. Those who had the tracheostomy done prior to 10 days of ventilation had better outcomes; however, these same subjects had lower acuity scores. Within 1 day of the procedure, ventilator settings were reduced, airway pressures were lower, and level of sedation was improved. CONCLUSIONS: Patients requiring a tracheostomy incur high resource use, and although the majority was transferred to other facilities, the number discharged directly home was low. Improved physiological parameters and reduced ventilator settings following the tracheostomy facilitated weaning from ventilation. IMPLICATIONS: Knowledge of characteristics and outcomes may assist in identifying interventions to reduce the need for tracheostomy or improve outcomes. In particular, the clinical nurse specialist can lead team initiatives to promote weaning prior rather than performing a tracheostomy as well as interventions postprocedure to improve discharge outcomes.

Use of electronic health record documentation by healthcare workers in an acute care hospital system.

Acute care clinicians spend significant time documenting patient care information in electronic health records (EHRs). The documentation is required for many reasons, the most important being to ensure continuity of care. This study examined what information is used by clinicians, how this information is used for patient care, and the amount of time clinicians perceive they review and document information in the EHR. A survey administered at a large, multisite healthcare system was used to gather this information. Findings show that diagnostic results and physician documents are viewed more often than documentation by nurses and ancillary caregivers. Most clinicians use the information in the EHR to understand the patient's overall condition, make clinical decisions, and communicate with other caregivers. The majority of respondents reported they spend 1 to 2 hours per day reviewing information and 2 to 4 hours documenting in the EHR. Bedside nurses spend 4 hours per day documenting, with much of this time spent completing detailed forms seldom viewed by others. Various flow sheets and forms within the EHR are rarely viewed. Organizations should provide ongoing education and awareness training for hospital clinical staff on available forms and best practices for effective and efficient documentation. New forms and input fields should be added sparingly and in collaboration with informatics staff and clinical team members to determine the most useful information when developing documentation systems.

Timing is everything: results to an observational study of mealtime insulin practices.

PURPOSE: The purpose of this study was to evaluate the timing and practices of blood glucose testing and rapid-acting insulin administration around mealtimes. DESIGN: This study used an observational, descriptive design to assess the time between blood glucose testing and insulin administration and the time between first bite of the meal and insulin administration. SETTING: The setting was 4 cardiology units in 2 hospitals within a large community healthcare system. SAMPLE: Sixty-four mealtime practice events at breakfast, lunch, and supper were observed. METHODS: Investigators directly observed the timing of rapid-acting insulin administration at 3 mealtime periods an assessed timing of blood glucose testing, food intake, and method of glucose reporting. RESULTS: Overall, 14% (n = 64) of the patients received blood glucose testing within 1 hour prior to insulin administration and insulin administration within 15 minutes of the meal. As separate elements, blood glucose testing was done within the defined ideal range 35% (n = 63) of the time, and insulin was administered within range 40% (n = 58) of the time. CONCLUSIONS: Timing for meals, blood glucose testing, and rapid-acting insulin administration varied significantly and was not well synchronized among the various patient caregivers with low achievement of ideal practices. IMPLICATIONS: Results to this study revealed opportunities for better coordination of mealtime insulin practices. Lack of coordination can lead to medication errors and adverse drug events. Further study should include effect of mealtime coordination on glycemic control outcomes and testing the effect of interventions on timing of mealtime insulin practices.

Assessment of an educational intervention on nurses' knowledge and retention of heart failure self-care principles and the Teach Back method.

BACKGROUND: Nurses must have optimum knowledge of heart failure self-care principles to adequately prepare patients for self-care at home. However, study findings demonstrate that nurses have knowledge deficits in self-care concepts for heart failure. METHODS: A quasi-experimental, repeated measures design was used to assess nurses' knowledge of heart failure self-care before, immediately after, and 3-months following an educational intervention, which also included the Teach Back method. Follow-up reinforcement was provided after the educational intervention. RESULTS: One hundred fifty nurses participated in the study. Significant differences were found between pre-test (65.1%) and post-test (80.6%) scores (p < 0.001). Teach Back proficiency was achieved by 98.3%. Only 61 participants completed the 3-month assessment of knowledge. In this group, mean knowledge scores increased significantly across all three measurements (p < 0.001): 66.5% (pre-test); 82.1% (post-test); 89.5% (follow up post-test). CONCLUSIONS: Participation in a comprehensive educational program resulted in increased nurses' knowledge of heart failure self-care principles and the knowledge was sustained and increased over time.

Perceptions of teamwork among code team members.

BACKGROUND: Cardiopulmonary arrest (CPA) teams, known as code teams, provide coordinated and evidenced-based interventions by various disciplines during a CPA. Teamwork behaviors are essential during CPA resuscitation and may have an impact on patient outcomes. OBJECTIVES: The purpose of this study was to explore the perceptions of teamwork during CPA events among code team members and to determine if differences in perception existed between disciplines within the code team. METHODS: A prospective, descriptive, comparative design using the Code Teamwork Perception Tool online survey was used to assess the perception of teamwork during CPA events by medical residents, critical care nurses, and respiratory therapists. RESULTS: Sixty-six code team members completed the Code Teamwork Perception Tool. Mean teamwork scores were 2.63 on a 5-point scale (0-4). No significant differences were found in mean scores among disciplines. Significant differences among scores were found on 7 items related to code leadership, roles and responsibilities between disciplines, and in those who had participated on a code team for less than 2 years and certified in Advanced Cardiac Life Support for less than 4 years. CONCLUSIONS: Teamwork perception among members of the code team was average. Teamwork training for resuscitation with all disciplines on the code team may promote more effective teamwork during actual CPA events. Clinical nurse specialists can aid in resuscitation efforts by actively participating on committees, identifying opportunities for improvement, being content experts, leading the development of team training programs, and conducting research in areas lacking evidence.

Clinical nurse specialist assessment of nurses' knowledge of heart failure.

PURPOSE/OBJECTIVE: Patients' self-management of heart failure (HF) is associated with improved adherence and reduced readmissions. Nurses' knowledge about self-management of HF may influence their ability to adequately perform discharge education. Inadequate nurse knowledge may lead to insufficient patient education, and insufficient education may decrease patients' ability to perform self-management. Prior to developing interventions to improve patient education, clinical nurse specialists should assess nurses' knowledge of HF. The purpose of this study was to determine nurses' knowledge of HF self-management principles. DESIGN: This was a prospective, exploratory, and descriptive online test. SETTINGS: There were 3 patient care settings: tertiary care teaching hospital, community hospital, and home healthcare division. SAMPLE: The sample was composed of 90 registered nurses who worked directly with patients with HF. METHODS: Nurses completed an online test of knowledge using the Nurses' Knowledge of Heart Failure Education Principles instrument. FINDINGS: Registered nurses (n = 90) completed the knowledge test instrument; their average score was 71% (SD, 10.8%) (range, 20%-90%). The percentage of correct items on each subscale ranged from 63.9% (SD, 30.0) for medications to 83.3% (SD, 25.0) for exercise. Only 8.9% of respondents achieved a passing score of greater than 85%, and a passing score was not associated with any demographic characteristics. CONCLUSIONS: Overall, nursing knowledge of HF self-management principles was low. Scores from our nurses were similar to those found in other studies. IMPLICATIONS: There is a need to develop interventions to improve nursing knowledge of HF self-management principles. Clinical nurse specialists can be instrumental in developing knowledge interventions for nurses.

Oropharyngeal secretion volume in intubated patients: the importance of oral suctioning.

BACKGROUND: Aspiration of secretions that accumulate above the cuff of the endotracheal tube is a risk factor for ventilator-associated pneumonia. Routine suctioning of oropharyngeal secretions may reduce this risk; the recommended frequency for suctioning is unknown. OBJECTIVES: To quantify the volume of secretions suctioned from the oropharynx of critically ill patients at 2 different intervals to assist in identifying a recommended frequency for oropharyngeal suctioning. METHODS: A prospective, repeated measure, single-group design was used. Twenty-eight patients who were orally intubated and treated with mechanical ventilation were enrolled; 2 were extubated during data collection, yielding a sample of 26 patients. The patients were suctioned at baseline with a deep suction catheter, and the volume and weight of secretions were recorded. The procedure was repeated at 2-hour and 4-hour intervals. RESULTS: Most of the patients were male (mean age, 49 years). Three suctioning passes were needed to clear secretions, with a mean time of 48.1 seconds. The mean volume of secretions at the 2-hour interval was 7.5 mL. Five patients required suctioning before the 4-hour interval. For the remaining 21 patients, the volume retrieved was 6.5 mL at the 2-hour interval and 7.5 mL at the 4-hour interval (P = .27). The 5 patients who required extra suctioning had significantly more secretions at the 2-hour interval (11.6 mL vs 6.5 mL; P = .05). CONCLUSIONS: A minimum frequency of oropharyngeal suctioning every 4 hours is recommended. However, more frequent suctioning may be needed in a subset of patients.

Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range.

BACKGROUND: Endotracheal tube cuff pressure must be kept within an optimal range that ensures ventilation and prevents aspiration while maintaining tracheal perfusion. OBJECTIVES: To test the effect of an intervention (adding or removing air) on the proportion of time that cuff pressure was between 20 and 30 cm H(2)O and to evaluate changes in cuff pressure over time. METHODS: A repeated-measure crossover design was used to study 32 orally intubated patients receiving mechanical ventilation for two 12-hour shifts (randomized control and intervention conditions). Continuous cuff pressure monitoring was initiated, and the pressure was adjusted to a minimum of 22 cm H(2)O. Caregivers were blinded to cuff pressure data, and usual care was provided during the control condition. During the intervention condition, cuff pressure alarm or clinical triggers guided the intervention. RESULTS: Most patients were men (mean age, 61.6 years). During the control condition, 51.7% of cuff pressure values were out of range compared with 11.1% during the intervention condition (P < .001). During the intervention, a mean of 8 adjustments were required, mostly to add air to the endotracheal tube cuff (mean 0.28 [SD, 0.13] mL). During the control condition, cuff pressure decreased over time (P < .001). CONCLUSIONS: The intervention was effective in maintaining cuff pressure within an optimal range, and cuff pressure decreased over time without intervention. The effect of the intervention on outcomes such as ventilator-associated pneumonia and tracheal damage requires further study.

Nurse staffing and patient outcomes in critical care: a concise review.

BACKGROUND: Studies over the past several decades have shown an association between nurse staffing and patient outcomes. Most of those studies were generated from general acute care units. Critically ill patients demand increased nurse staffing resources and nurses who have specialized knowledge and skills. Appropriate nurse staffing in critical care units may improve the quality of care of critically ill patients. OBJECTIVES: To review the literature evaluating the association of nurse staffing with patient outcomes in critical care units and populations. METHODS: An annotated review of major nursing and medical literature from 1998 to 2008 was performed to find research studies conducted in intensive care units or critical care populations where nurse staffing and patient outcomes were addressed. RESULTS: Twenty-six studies met inclusion for this review. Most were observational studies in which outcomes were retrieved from existing large databases. There was variation in the measurement of nurse staffing and outcomes. Outcomes most frequently studied were infections, mortality, postoperative complications, and unplanned extubation. Most studies suggested that decreased nurse staffing is associated with adverse outcomes in intensive care unit patients. CONCLUSIONS: Findings from this review demonstrate an association of nurse staffing in the intensive care unit with patient outcomes and are consistent with findings in studies of the general acute care population. A better understanding of nurse staffing needs for intensive care unit patients is important to key stakeholders when making decisions about provision of nurse resources. Additional research is necessary to demonstrate the optimal nurse staffing ratios of intensive care units.

Assessment of endotracheal cuff pressure by continuous monitoring: a pilot study.

BACKGROUND: Endotracheal tube cuff pressure must be maintained within a narrow therapeutic range to prevent complications. Cuff pressure is measured and adjusted intermittently. OBJECTIVES: To assess the accuracy and feasibility of continuous monitoring of cuff pressure, describe changes in cuff pressure over time, and identify clinical factors that influence cuff pressure. METHODS: In a pilot study, data were collected for a mean of 9.3 hours on 10 patients who were orally intubated and receiving mechanical ventilation. Sixty percent of the patients were white, mean age was 55 years, and mean intubation time was 2.8 days. The initial cuff pressure was adjusted to a minimum of 20 cm H2O. The pilot balloon of the endotracheal tube was connected to a transducer and a pressure monitor. Cuff pressure was recorded every 0.008 seconds during a typical 12-hour shift and was reduced to 1-minute means. Patient care activities and interventions were recorded on a personal digital assistant. RESULTS: Values obtained with the cufflator-manometer and the transducer were congruent. Only 54% of cuff pressure measurements were within the recommended range of 20 to 30 cm H2O. The cuff pressure was high in 16% of measurements and low in 30%. No statistically significant changes over time were noted. Endotracheal suctioning, coughing, and positioning affected cuff pressure. CONCLUSIONS: Continuous monitoring of cuff pressure is feasible, accurate, and safe. Cuff pressures vary widely among patients.